Internal Medicine Clinic Referral

Internal Medicine Clinic Referral

Phone: 705-728-9090 Ext: 23300

Fax: 705-728-3039

Referring Physician:

09/15/2021

Discipline: _____________ Date: ___________

Patient Name: __________________________________ D.O.B (dd/mm/year) _______________

Health Card Number: __________________________ Phone Number: _______________________

Relevant Labs Included?

Yes

No

Relevant Imaging Studies Included?

Yes

No

Previous Consultation Report Included?

Yes

No

*Incomplete referral form will delay appropriate triage and referral time

Reason for Referral:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

RVH ER Referral

Less than 2 weeks

4 weeks

_____ ___

RVH Inpatient Discharge

Urgent (1-2 days)

Less than 2 weeks

_______________

DM with Diabetes Educator

Less than 2 weeks

3 months

_______________

VTE or anticoagulation

Less than 2 weeks

3 months

_______________

Perioperative consult

Date of surgery: _________________________

Medicine Treatment Clinic

Please indicate:

Community Referral

Benign Hematology Referral

Iron infusion

IVIG

Phlebotomy

4 weeks

3 months

6 months

Less than 2 weeks

Please indicate reason for referral:

Mild cytopenias (ANC greater than 1.0, Plts greater than 50)

Anemia

Polycythemia

4- 6 weeks

The following should go directly to SMRCP Malignant

Hematology Clinic: Multiple myeloma or MGUS,

lymphocytosis, thrombocytosis, pancytopenia concerning

for bone marrow failure (Hb less than100, ANC less than

1.0, Plts less than 50, or abnormalities on peripheral blood

film such as blasts)

Signature Referring Physician: ___________________________ Billing Number: _____________

Telephone Number: ________________________Fax Number: __________________________

RVH-1695 20-June-2018

Page 1 of 2

201 Georgian Drive | Barrie ON | 705.728.9802

rvh.on.ca

R.IMCREF

NAME:

DOB:

Internal Medicine Clinic Referral

HRN:

For Office Use Only:

First Appointment

Appointment

Date:

Time:

Reminder

Yes _______________

No

Arrived:

Yes

No

Second Appointment

Appointment

Date:

Time:

Reminder:

Yes _______________

No

Arrived:

Yes

No

Third Appointment

Appointment

Date:

Time:

Reminder:

Yes _______________

No

Arrived:

Yes

No

Reason for 3rd appointment:

No GP

Follow up labs

Target triage

time achieved:

Yes

No

Diagnosis unclear

IV infusion

Referral

appropriate:

Yes

No

RVH-1695 20-June-2018

Page 2 of 2

201 Georgian Drive | Barrie ON | 705.728.9802

rvh.on.ca

R.IMCREF

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